Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
Are you incorporating TTFields into treatment protocols for locally advanced pancreatic cancer based on the PANOVA-3 study?
Most medical and radiation oncologists I have spoken to believe that TTFields offer benefit based on the PANOVA-3 trial and support routine use once it is FDA-approved. One of the outstanding questions relates to the use of definitive radiation therapy, which was not included in either arm, but is a...
How will you weigh the positive PFS but negative OS benefit when discussing Dato-DXd with patients?
I think it will be increasingly difficult to prove OS in an environment where patients should have access to highly active ADCs at progression. Positive PFS is meaningful for our patients when associated with a well-tolerated regimen that has a favorable dosing schedule and quality of life metrics.
What supportive care measures do you prioritize to manage or prevent toxicity in patients receiving Dato-DXd?
My supportive care approach is centered around early identification and management of interstitial lung disease (ILD) and mucositis, both of which were observed in the TROPION-Breast01 trial. Twelve patients (3.3%) in the Dato-DXd arm had adjudicated drug-related ILD/pneumonitis. I routinely obtain ...
How does the safety profile of Dato-DXd influence its use in patients with comorbidities or frailty compared to standard chemotherapy?
There were fewer high-grade adverse events seen with Dato-DXd compared to investigator’s choice chemotherapy (20% vs. 45%, respectively), though we do see higher rates of nausea, stomatitis, fatigue, alopecia, and dry eyes or keratitis with Dato-DXd compared to chemotherapy. With the use of prophyla...
How will you sequence Dato-DXd among available therapies for HR positive, HER2-0 metastatic breast cancer?
While the approval of Dato-DXd for advanced HR+ HER2- breast cancer offers another TROP2 ADC with an improvement in clinical outcomes, there remain several unanswered questions and uncertainty about how to best utilize and sequence the ADCs for metastatic breast cancer. For patients with HR+ HER2 lo...
What factors should be considered when deciding between datopotamab deruxtecan and sacituzumab govitecan for a patient with metastatic breast cancer?
When choosing between Dato-DXd and SG, I consider payload differences, toxicity profiles, and prior therapies. Dato-DXd delivers DXd (an exatecan derivative), while SG delivers SN-38 (active irinotecan metabolite). SG demonstrated an OS benefit in TROPiCS-02 (JCO 2023), whereas Dato-DXd showed a PFS...
How, if at all, does the spectrum of HER2 positivity impact efficacy of T-DXd in the frontline setting?
Multiple studies have shown that HER2 3+ disease is a predictor for exceptional (long-term) response to first-line THP, and conversely, patients with HER2 2+/FISH positive disease are less likely to experience an exceptional response to THP. While I have not seen a subset analysis by HER2 2+ vs 3+ p...
What disease characteristics will guide your choice of alpelisib plus fulvestrant (per SOLAR-1) versus capivasertib plus fulvestrant (per CAPItello-291) in PIK3CA mutated advanced ER+/HER2- breast cancer after progression on 1L ET regimen, given both are now approved in this population?
In the absence of head-to-head comparison, I would use cross-trial comparison to compare the efficacy and safety of alpelisib vs capivasertib. mPFS are similar for both: HR 0.65 (11 vs 5.7 months) for alpelisib (SOLAR-1); and mPFS HR 0.6 (7.2 vs 3.6 months) for capivasertib (CAPItello-291). Therefor...
What is the drug of choice in order of preference for neuropathy associated with different agents used for breast cancer treatment?
Unfortunately, many of the large trials have not identified a strategy that is effective for CIPN. It is important to tell patients to avoid some supplements. Studies have shown that acetyl-l-carnitine can make the symptoms worse. There is some evidence that exercise may result in decreased symptoms...
How do you approach an otherwise healthy patient with an incidental 1 mm GIST involving the serosal surface in terms of staging workup, EGD, and surveillance?
These incidental "micro-GISTs" are not likely to become a clinical problem. Interestingly, you describe a "serosal" lesion which would not get picked up on endoscopy anyway, but not unreasonable to check again in a year with a CT AP and EGD. I don't think we have any evidence to support continued lo...